Review of killerās care finds āa series of errorsā
A review has found āa series of errors, omissions and misjudgementsā in the care of a killer who stabbed three people to death in the Nottingham attacks.
Barnaby Webber and Grace OāMalley-Kumar, both 19, and 65-year-old Ian Coates were killed by Valdo Calocane, who was psychotic and suffering from paranoid delusions, on 13 June 2023.
The review, published by the Care Quality Commission (CQC) on Tuesday, said without action, the issues identified would ācontinue to pose an inherent risk toā¦ public safetyā.
The government met the victimsā families last week and called for the CQCās recommendations to be implemented in mental healthcare across England.
The families confirmed the meeting with the Department of Health and the Attorney Generalās Office, which both told the BBC that the prime ministerās commitment to a judge-led inquiry into the deaths still stood.
However, the families have insisted the inquiry must be statutory, with the power to compel witnesses to provide evidence.
Last year, Calocane went on a rampage through the streets of Nottingham, killing students Mr Webber and Ms OāMalley-Kumar with a knife as they returned from a night out, before stabbing Mr Coates to death near the school where he worked as a caretaker.
He then stole Mr Coatesās van and drove into pedestrians Wayne Birkett, Marcin Gawronski and Sharon Miller, inflicting serious injuries.
He was sentenced to a hospital order in January and told he would be in a high-security facility āvery probablyā for the rest of his life.
Tuesdayās report looked into Calocaneās care by Nottinghamshire Healthcare NHS Foundation Trust from May 2020 to September 2022.
The victimsā families ā who have repeatedly called for a public inquiry into the case ā said they were āfailed by multiple organisations pre and postā the killings.
In a joint statement, they added: āThis report demonstrates gross, systemic failures in the mental health trust in their dealings with Calocane ā from beginning to end.
āSadly, this is the first of what we expect to be a series of damning reports concerning failures by public bodies in the lead-up to the killings of our loved ones, and beyond.
āProgress is slowly being made and we will continue in our fight to ensure there is full organisational and individual accountability.ā
Dr Sanjoy Kumar, Ms OāMalley-Kumarās father, told the BBC that the families would like the scope of the inquiry to be āas wide as possibleā.
āWe would like it to be a statutory public inquiry led by a judge, and one that has real teeth to make a difference and change things in our country,ā he added.
āWe have to concentrate on Nottingham first and learn from what went wrong because these systems are parallel across the country.ā
In compiling its report, the CQC reviewed Calocaneās records alongside 10 other cases āto enable benchmarkingā.
The CQC said it had āengagedā with the families of Calocane and the victims, but the watchdog did not interview or speak to any staff members involved in the offenderās care at the trust.
The report found the 32-year-old ā a former University of Nottingham student ā had first come into contact with the trust in May 2020 during the first Covid-19 lockdown.
Documents showed he was āacutely unwellā, and was diagnosed with paranoid schizophrenia and sectioned four times in less than two years.
But the report said ākeyā risks had either been missed or omitted, including the refusal of medicine, ongoing and persistent symptoms of psychosis, levels of violence against others when his psychosis was not managed well, and Calocaneās escalation of violence towards others in the later stages of his care under the trust.
It also found āpoor planning and engagementā with the killer and his family, who raised concerns about his mental state with the trust and to BBC Panorama in their first interview.
āIt is clear that after four admissions in two years, and repeated disengagement and refusal to take medicine, [Calocane] required a much more robust package of care,ā the report said.
āMore assertive engagement and restrictive measures were crucial to managing his illness and the risk he posted to others when unwell.ā
The CQC issued five recommendations to the trust, including ensuring that staff were aware of the importance of involving and engaging patientsā families, and implementing ārobust discharge policy and processesā.
Responding to the CQC review, Health Secretary Wes Streeting said: āI want to assure myself and the country that the failures identified in Nottinghamshire are not being repeated elsewhere.
āI expect the findings and recommendations in this report to be considered and applied throughout the country so that other families do not experience the unimaginable pain that Barnaby, Grace and Ianās family are living with.ā
In its report, the CQC said NHS England would be carrying out āmore detailed scrutinyā of Calocaneās wider interaction with mental health services in its āindependent homicide reviewā.
The government said measures the NHS had already taken included issuing guidance to trusts ā reiterating instructions not to discharge patients with serious mental health issues if they did not attend appointments ā and ensuring every service provider had āclear policies and practice in place to treat patientsā.
Chris Dzikiti, interim chief inspector of healthcare at the CQC, added: āThe issues we have identified at Nottinghamshire Healthcare NHS Foundation Trust are not unique.
āWe found systemic issues with community mental health care, including a shortage of mental health staff, a lack of integration between mental health services and other healthcareā¦ and support services, including the police.
āWithout action, this will continue to pose an inherent risk to patient and public safety.ā
Timeline of Valdo Calocaneās contact with the trust
The CQC has released a timeline of Calocaneās contact with the local NHS trust. It said:
- 24 May 2020 ā Calocane is arrested for the first time. He is sent home after a mental health assessment but is re-arrested an hour later
- 25 May 2020 ā Officials section Calocane for the first time at Highbury Hospital in Nottingham
- 14 July 2020 ā Calocane is involved in a police incident and sectioned for the second time
- 3 September 2021 ā Calocane is sectioned for the third time and taken to an independent hospital
- 18 January 2022 ā Calocane is detained after an assault on another student
- 28 January 2022 ā He is sectioned for the fourth time
- 23 September 2022 ā Calocane is discharged to a GP due to non-engagement
Mr Dzikiti added āpoor decision-making, omissions and errors of judgementā had contributed to a situation in which a patient with āvery serious mental health issues did not receive the support and follow-up he neededā.
āWhile it is not possible to say that the devastating events of 13 June 2023 would not have taken place had Valdo Calocane received that support, what is clear is that the risk he presented to the public was not managed well and that opportunities to mitigate that risk were missed,ā he said.
āThere is action that can, and must, be taken to better support people with serious mental health issues and provide better protection for the public in the future.ā
Panorama ā The Nottingham Attacks: A Search for Answers
In June 2023, Barnaby Webber, Grace OāMalley-Kumar and Ian Coates were stabbed to death by Valdo Calocane. Reporter Navtej Johal investigates his history of mental ill health and the care he received.
Watch on BBC iPlayer from 20:00 BST on Monday.
Ifti Majid, chief executive of the NHS trust, offered his āsincere apologiesā to the families of the victims.
āWe acknowledge and accept the conclusions of this report and have significantly improved processes and standards since the review was carried out,ā he said.
āOur teams have much more contact with people waiting to be seen in the community to agree crisis plans and ensure they have an up-to-date risk assessment even when they are struggling to engage with our services or primary care.
āWe have a clear plan to address the issues highlighted and are doing everything in our power to understand where we missed opportunities and learn from them.ā
The report is the latest of a series of reviews, including by the Independent Office for Police Conduct (IOPC) into both Leicestershire and Nottinghamshire Police.
A review into the Crown Prosecution Service (CPS) found that while prosecutors had been right to accept Calocaneās pleas of manslaughter on the basis of diminished responsibility, they could have handled the case better.
And in May, a judge ruled Calocaneās sentence was not unduly lenient, following a referral from the attorney general.
Analysis
By Navtej Johal, BBC Panorama
There are several points mentioned in this review which support the view of Calocaneās family that opportunities to provide him with the care he needed before the tragic events in Nottingham in 2023 were missed.
In their first interview, Elias and Celeste, Calocaneās brother and mother, told me that they believed the mental health system was ābrokenā and ānot fit for purposeā.
One of many examples of the problems in his care highlighted by the CQC is the decision to discharge him to his GP for not engaging with mental health services nine months before the killings.
The review says that decision ādid not adequately consider or mitigate the risks of relapseā.
Celeste Calocane said she felt that at that moment, the community mental health team āwash their hands and say, āOK, thatās itā.ā
They will be hoping that the recommendation to strengthen policy and processes that āconsider the circumstances surrounding discharge and whether discharge is appropriateā are among many that are acted upon.
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